EMPLOYMENT APPLICATION

EMPLOYMENT APPLICATION
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An Equal Opportunity Employer
Type or print clearly in ink and sign this application.
If you do not do so, the application will be returned.
You must complete the application even if you are submitting a resume.
TerraMark is an equal opportunity employer and does not discriminate in recruiting, hiring,
compensation, promotion or other employment terms based on race, color, religion, national
origin, citizenship, sex, age, disability, or veteran status. This applies to all categories of
employment: management, professional, technical, and all other staff positions. All employment
decisions will be made solely upon the basis of the individual's qualifications as related to the
requirements of the position being filled. The information requested in this application will be
used in a nondiscriminatory manner. If you are certified, registered or licensed in your
profession, you will be asked to provide proof of your professional standing.
In accordance with the immigration and Reform Control Act of 1986, proof of authorization to be
employed in the United States will be required of all prospective team members. Failure to
establish such proof will prohibit or discontinue employment.
In order to be considered for employment, you should attach the following:
Copy Of Valid Driver's License
Proof of Current Auto Insurance (Document must show that you are a covered driver)
Copy of Social Security Card
Certification/Professional License (if applicable)
CERTIFICATION: Read carefully before signing and dating. Unsigned applications will be
returned.
I certify that all information on this application is correct. I authorize any agent or employee of
TerraMark to verify this information and to release it to anyone who may consider me for
appointment. I understand that intentionally providing false information on this form or
attachments is a violation of state law. I further certify that either: 1) I have not pled guilty or
been convicted of a drug-related criminal offense; or 2) if I have been convicted of a drugrelated criminal offense, it has been more than three (3) months since my first conviction, or
more than five (5) years since a second or subsequent conviction.
X
Signature
X
Date
GENERAL INFORMATION
Social Security Number
Daytime Telephone Number
Last Name
First Name
M.I.
Birth, Maiden or Other Names Used Past and Present
Apt #
Street Address
City
Zip Code
State
County
In the event of an emergency please indicate the person you wish us to contact
Name
Address
Phone Number
PERSONAL RECORD
1.
Are you Age 18 or older?
2.
Have you ever applied to TerraMark?
3.
Have you ever been employed by TerraMark?
4.
Are you related to any TerraMark employees?
YES
NO
YES
if yes, when?
NO
YES
NO
YES
If yes, when & where?
NO
If yes, give name(s) and relationship(s)
5.
Are you a United States citizen?
6.
Are you an alien authorized to work in the United States?
7.
Military service
8.
Reserve status (if applicable)
9.
YES
NO
YES
Date Entered
NO
N/A
If yes, provide visa type
Type of discharge
Date Discharged
Have you ever been convicted of a crime other than a minor traffic violation?
YES
NO
If yes, please explain
10. Have you ever been convicted of a felony?
YES
11. What type of employment are you interested in?
12. Positions applied for (limit of 2 at one time):
13.
High School Graduate or
YES
Equivalent (GED)?
Full Time
If yes, attach an explanation.
Part Time
1.
Minimum pay required: $
EDUCATION:
NO
Temporary
2.
/ hr
Vocational/Business School:
Number of Months:
Date Completed:
Field of Study:
NO
PLEASE LIST EXACT COLLEGE HOURS BELOW:
NAME OF COLLEGES
OR UNIVERSITIES ATTENDED
CREDIT RECEIVED
Qtr Hrs
Sem Hrs
FIELD/AREA OF CONCENTRATION
Major
Hrs
Minor
TYPE OF DEGREE
Hrs
(BA/BS/MA/PhD)
DATE DEGREE
COMPLETED
2
LICENSES AND CERTIFICATIONS
Type of License/Certificate
Specialization / Endorsements
License/Certificate Number
Expiration (Mo./Yr.)
PERSONAL REFERENCES (CANNOT BE RELATIVES)
Relationship
Name
Address
Phone #
SKILLS (Check all that apply)
Data Entry
Calculator touch
Typing WPM:
Other:
Foreign Language (level of fluency)
Personal Computer (list software)
WORK HISTORY (Last 15 years beginning with present or most recent experience)
Include military and volunteer experience. If you worked for the same employer but held different jobs describe each separately. Describe in detail the specific duties
beginning with your primary duties. If you need additional space attach additional sheets, which contain the same information requested in this section. Include the
number and types of employees under your supervision and give percentage of time for each duty. Failure to give complete and detailed information regarding each job
held may result in your disqualification from employment consideration.
Are you employed?
YES
NO
May we contact your present employer?
Current or Last Employer:
From (MM/YYYY)
State:
ZipCode
Check One:
Check One:
Supervisor's Name & Title:
Reason for leaving:
%
NO
Your Job Title:
Address:
City:
YES
To (MM/YYYY)
Paid
Full Time
May We Contact Employer?
YES
NO
Volunteer
Intern
Hours per Week
Annual Salary
Part Time
Supervisor's Phone #
# and type of employess you supervised
Describe in detail your job duties and the average percent of work time you spent on each duty.
3
WORK HISTORY (cont'd)
Continue additional work history below. If you need more space, attach additional sheets which contain the same information requested in this section.
Employer:
Your Job Title:
Address:
From (MM/YYYY)
City:
State:
ZipCode
Check One:
Check One:
Paid
Full Time
May We Contact Employer?
Supervisor's Name & Title:
YES
Reason for leaving:
%
NO
Volunteer
Intern
Hours per Week
Annual Salary
Part Time
Supervisor's Phone #
# and type of employess you supervised
Describe in detail your job duties and the average percent of work time you spent on each duty.
Employer:
Your Job Title:
Address:
From (MM/YYYY)
City:
State:
ZipCode
Check One:
Check One:
To (MM/YYYY)
Paid
Full Time
May We Contact Employer?
Supervisor's Name & Title:
YES
Reason for leaving:
%
To (MM/YYYY)
NO
Volunteer
Intern
Hours per Week
Annual Salary
Part Time
Supervisor's Phone #
# and type of employess you supervised
Describe in detail your job duties and the average percent of work time you spent on each duty.
UNEMPLOYMENT RECORD:
Account for all periods of unemployment due to non-medical reasons during the last five years or since you left school (4 weeks duration or longer).
From
To
Reason
4